MEDICARE: SOUTHEAST RADIOLOGY ASSOCIATES PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1881239093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST RADIOLOGY ASSOCIATES PLLC

Provider Business Mailing Address
First Line	:	10926 DAVID TAYLOR DR STE 120
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1042
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10926 DAVID TAYLOR DR STE 120
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-1042
Country	:	US
Telephone Number	:	704-345-0789
Fax Number	:

Authorized Official
Title or Position	:	MBR
Name	:	JONATHAN LOZEVSKI
Credential	:	MD
Telephone Number	:	704-345-0789

Provider Enumeration Date	:	11/12/2019
Last Update Date	:	11/12/2019

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